PARIS (FRONTLINE MEDICAL NEWS) – Aggressiveness deserves to be incorporated in the next Diagnostic and Statistical Manual of Mental Disorders update as a new clinical criterion triggering application of the “with mixed features” specifier in patients diagnosed with a major depressive episode, Norma Verdolini, MD, said at the annual congress of the European College of Neuropsychopharmacology.

“Aggressiveness might be a trait component of bipolarity and a diagnostic indicator of ‘mixicity’ in patients with a major depressive episode. This has implications for the therapeutic strategy,” said Dr. Verdolini of the bipolar disorders unit at the University of Barcelona Institute of Neurosciences.

Moreover, aggressiveness in the context of a major depressive episode (MDE) may be an indicator of increased risk for suicidal behavior, according to her post-hoc analysis of the Bipolar Disorders: Improving Diagnosis, Guidance and Education study.

The BRIDGE-II-MIX study was a cross-sectional observational study of 2,811 adults with MDE at 239 centers in eight European countries ( J Clin Psychiatry. 2015 Mar;76[3]:e351-8) . Three hundred ninety-nine participants (14.2%) met the operational definition of physical or verbal aggressiveness used in Dr. Verdolini’s new post-hoc analysis.

Statistically significant and clinically meaningful differences were found between MDE patients with aggressiveness (MDE-aggro) and MDE without aggressiveness. For example, the MDE-aggro group was twice as likely to meet DSM-IV-TR criteria for bipolar disorder I. Twenty-seven percent of the MDE-aggro group met DSM-5 criteria for a mixed state, meaning both depressed mood and mania in the same episode, compared with just 4% of the MDE-no-aggro group.

The MDE-aggro patients also had a strikingly greater prevalence of comorbid borderline personality disorder, by a margin of 20% versus 4%. They had a younger mean age at their first depressive episode: 29.9 years old, compared with 36.1 in the MDE-no-aggro group. The MDE-aggro patients had more prior mood episodes and a greater number of lifetime suicide attempts. In addition, they had significantly more severe depression, mania, and bipolar disorder scores on the Clinical Global Impression Scale for Bipolar Disorder .

A multivariate logistic regression analysis performed after excluding patients with borderline personality disorder identified numerous clinical variables that were significantly associated with aggression.

“Our results should prompt reconsideration of the diagnostic criteria for the mixed features specifier. The detection of aggression in MDE could represent a therapeutic target in personalized pharmacological treatment for bipolar disorder,” Dr. Verdolini concluded.

The BRIDGE-II-MIX study was sponsored by Sanofi-Aventis. Dr. Verdolini reported receiving research funding from the company.


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